NR 602 Well Child Soap Note

NR 602 Well Child Soap Note

NR 602 Well Child Soap Note

Jo., 5-year-old, Female

S.

CC- Well child visit

HPI- The mother denies any recent illnesses in either child and reports they are here for their check-up. She was a full-term gestation, born cesarean section, with no complications in pregnancy. Mother smoked 1 PPD during her pregnancy. There have been no hospitalizations; she eats three meals a day and two snacks. There is a great deal of juice, soda, and processed foods given in the house. The patient currently lives with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works. Jo will be starting kindergarten this fall in the community’s elementary school.

Current medications- Chewable children’s multivitamin with iron

Allergies- NKA

Immunizations- Hep B, 2 months – Hep B, DTaP, HIB (COMVAX), PCV13, IPV, 4 months – DTaP, HIB (COMVAX), PCV13, IPV, 6 months DTaP, IPV, 6 months – DtaP, PCV 13, IPV. Hep B, 12 months – MMR, Varicella, Hep A, PCV 13, 18 months – DtaP, Hep A

PMH- Full-tern gestation delivered C-section, birth weight= 7lb 4oz, no complications during pregnancy, mother smoked 1 PPD throughout pregnancy, no hospitalizations

Social history- Both children currently live with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works. Jo will be starting kindergarten this fall in the community’s elementary school. They eat three meals and two snacks a day. There is a great deal of juice, soda, and processed or quick foods given in the house. They do brush their teeth twice a day, ride in car seats in the car, and play vigorously both indoors and outdoors at home.

Family history- Maternal and paternal parents are smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia.

ROS:

Constitutional- “waking frequently to ‘play’”

HEENT- Not reported

Skin- Not reported

Respiratory- Not reported

Gastrointestinal-  Not reported

Genitourinary- Not reported

Neurological- Not reported

Musculoskeletal- Not reported

Hematological- Not reported

Lymphatics- Not reported

Psychiatric- Not reported

 

98. V/S:  Height: 109 cm, Weight: 27 kg, B/P:102/60, T: 98.2, HR: 88 BMP/reg., Resp: 18, reg, non-labored, SpO2: 99%, BMI- 22.7

General: Cooperative, talkative, appropriate

HEENT: head normocephalic atraumiatic, hair thick and distributed throughout entire scalp; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; fundoscopic exam unremarkable; vision by Snellen exam 20/50 in her left eye, 20/40 in her right, and 20/30 together; tympanic membranes intact, unremarkable; pinna/tragus w/o tenderness; nares patent, unremarkable bil; pharynx unremarkable tonsils 1/4 bil; primary tooth eruption to include first molars upper and lower; no loose teeth; oral exam unremarkable; neck supple w/o lymphadenopathy; thyroid small, firm, equal bil.

Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored

Abdomen: sl. rounded normoactive bowel sounds throughout, soft, non-tender, no masses, or organomegaly

Peripheral pulses: reg., equal., intact bil radial and pedal;

GU: labia majora and minora intact, no erythema or discharge.

Musculoskeletal: MAE. Able to do deep knee bends; hop on one foot on right leg but not left with any balance, tries but tumbles; able to balance on each leg for 10 seconds.

Cognitive Development: Able to state name and age; can write her own name; able to recall three friend’s names; knows all colors and can count to 13; dresses herself and has control of bowels and bladder; verbal throughout exam; all of speech clear and recognizable.

A.

Primary Diagnosis:

Encounter for routine child health examination without abnormal findings (ICD10: Z00.129): Well child examinations are very important to ensure the child is up to date with his or her immunizations and to make sure the child is growing and developing appropriately for his or her age (Hollier, 2016). Education also takes place on important aspects of the child’s development they should be going through.  

Secondary Diagnoses:

Other stressful life events affecting family and household (Z63.7) – Mom and dad are separated and now they are living with the grandparents. Father is in the picture but is 2 hours away. When there is a change in a household, especially abrupt ones for a child, the stress of a child can increase, and the child may act out (Hollier, 2016).

NR 602 Well Child Soap Note

Behavioral insomnia of childhood, sleep-onset type (Z73.810) – Insomnia is a common sleep disorder. If you have it, you may have trouble falling asleep, staying asleep, or both. As a result, you may get too little sleep or have poor-quality sleep.  Sleep studies, medications, and counseling can all help with this diagnosis (Maness, & Khan, 2015). It has been difficult to get the children to go to bed and stay in bed at night.

Pediatric BMI greater than or equal to 95^th percentile for age (Z68.54) – Jo’s BMI is 22.7 which places her above the 95^th percentile for body mass index for her age.

Nutritional Deficiency related to diet (ICD10: E63.9): A nutritional diet is extremely important for children.  Children can develop less illnesses and have a better quality of life by eating fresh fruits and vegetables. The parents are the primary caretakers and need to be educated on healthy food choices to decrease obesity in their children (National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 2016).

P.

Additional tests- none

Rx- According to the CDC (2016), recommended immunization schedule for persons aged 0 through 18 years, Jo is due for the following vaccinations to be given in the office.

1. Diphtheria/tetanus toxoids and acellular pertussis vaccine (DTap)- 5th dose

0.5 ml given IM (Epocrates, 2015) (CDC, 2016).

2. Poliovirus vaccine, inactivated (Ipol)- 4th dose

0.5ml given IM (Epocrates, 2015) (CDC, 2016).

3. Measles/mumps/rubella vaccine, live (MMRII)- 2nd dose

0.5ml given SC (Epocrates, 2015) (CDC, 2016).

4. Varicella vaccine (VAR)- 2nd dose

0.5ml given SC (Epocrates, 2015) (CDC, 2016).

 

Anticipatory Guidance for Jo:

Topic: Nutrition

Target Age Range: (Middle Childhood 5-10 years old)

According to the Bright Futures Guidelines for a 5-year-old Jo has several priorities for this first visit. They first recommend that the concerns of the parents be addressed first. Then, school readiness, mental health, nutrition and physical activity, oral health, and safety should all be addressed. (Strasburger, 2015).

Definition: As for Jo’s dietary intake it is good that she is eating three meals a day with two snacks, but the large quantity of juice, soda, and processed foods are not good. During this age group it is the perfect time to counsel them on making appropriate choices on what to eat and drink to promote nutritional health. Guidance should be provided, or a referral can be given if the family needs nutritional helps due to cultural, religious, or financial reasons. One of these guidance items that should be discussed heavily in Jo’s case is the limitation of high-fat and low-nutrient foods and drinks, such as candy, salty snacks, fast foods, and soda. (Strasburger, 2015).

Educational points:

According to the CDC (2009) clinical growth charts, Jo’s BMI is 22.3 which are above the 95th percentile for body mass index for her age. Jo is considered obese for her age and needs help with healthy eating habits. The mother needs to be educated in being a healthy role model for Jo; children often mimic what they see from their parents. Jo should be fed more fruits, vegetable, nuts, seeds and whole grain foods. Jo should be getting at least 60 minutes of exercise a day and TV time should be limited to 2 hours a day. Foods high in fat and sugar should be limited to one treat a day (NIDDK, 2013).

The parents should be encouraged to support their children in being physically active and to be physically active together as a family. Parents of children with special health care needs should also be encouraged to allow their children to participate in regular physical activity or cardiovascular fitness within the limits of their medical conditions. (Strasburger, 2015). NR 602 Well Child Soap Note.

As for Jo, she should be encouraged to be physically active for at least 60 minutes total every day. It doesn’t have to happen all at once, but can be split up into several periods of activity over the course of the day. (Strasburger, 2015)

The family should also limit the amount of time your child watches TV and plays video games or is on the computer to no more than 2 hours altogether each day. Any TVs from your child’s bedroom should be removed. (Strasburger, 2015)

Referral- Due to the results of Jo’s Snellen test she should be referred to an ophthalmologist for a further evaluation (Charbeck, 2015).

Follow up- Call the office with any problems or concerns. Return in 1 year for well child visit. (American Academy of Pediatrics, 2016)

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References

American Academy of Pediatrics. (2015). Recommendations for Preventative Pediatric Health Care. Retrieved from https://www.aap.org/en-us/Documents/periodicity_schedule.pdf

Centers for Disease Control and Prevention. (CDC). (2016 S). Recommended Adult Immunization Schedule. Retrieved from http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf.

Centers for Disease Control and Prevention (CDC). (2016) Retrieved October 26, 2017, from Clinical Growth Charts: http://www.cdc.gov/growthcharts/clinical_charts.htm

Charbeck, E. (2015) Pediatrics: Normal vital signs. Retrieved from: http://emedicine.medscape.com/article/2172054-overview.

Epocrates. (2017). Retrieved from MMRII: https://online.epocrates.com/rxmain

Epocrates. (2017). Retrieved from DTap: https://online.epocrates.com/rxmain

Epocrates. (2017). Retrieved from Escitalopram: https://online.epocrates.com/rxmain

Epocrates. (2017). Retrieved from Ipol: https://online.epocrates.com/rxmain

Epocrates. (2017). Retrieved from VAR: https://online.epocrates.com/rxmain

Fenstermacher, K. & Hundson, B. T. (2016). Practice Guidelines for Family Nurse Practitioners (4th ed.). St. Louis, MO: Elsevier.

Goroll, A. H. & Mulley, A. G. (2014). Primary Care Medicine (7th ed.). Wolters Kluwer Health.

Hollier, A. (2016). Clinical guidelines in primary care. Scott, LA.: Advanced Practice Education Associates

Kane, R., Ouslander, J., Abrass, I. & Resnick, B. (2013). Essentials of clinical geriatrics (7th ed.). China: McGraw Hill.

Maness, D. L., & Khan, M. (2015). Nonpharmacologic management of chronic insomnia. American Family Physician, 92(12), 1058-1064.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2013, June). Retrieved May 5, 2016, from Helping your overweight child: http://www.win.niddk.nih.gov